Urination

Manneken Pis (along with the corresponding female Jeanneke Pis, in limestone) is a bronze sculpture in Brussels, Belgium.

Urination is the release of urine from the urinary bladder through the urethra to the urinary meatus outside of the body. It is also known medically as micturition, voiding, uresis, or, rarely, emiction, and known colloquially by various names including tinkling, peeing, weeing, and pissing.

In healthy humans (and many other animals) the process of urination is under voluntary control. In infants, some elderly individuals, and those with neurological injury, urination may occur as an involuntaryreflex. It is normal for adult humans to urinate up to seven times during the day.[1]

Smooth muscle bundles pass on either side of the urethra, and these fibers are sometimes called the internal urethral sphincter, although they do not encircle the urethra. Further along the urethra is a sphincter of skeletal muscle, the sphincter of the membranous urethra (external urethral sphincter). The bladder's epithelium is termed transitional epithelium which contains a superficial layer of dome-like cells and multiple layers of stratified cuboidal cells underneath when evacuated. When the bladder is fully distended the superficial cells become squamous (flat) and the stratification of the cuboidal is reduced in order to provide lateral stretching.

The physiology of micturition and the physiologic basis of its disorders are subjects about which there is much confusion, especially at the supraspinal level. Micturition is fundamentally a spinobulbospinal reflex facilitated and inhibited by higher brain centers such as the pontine micturition center and, like defecation, subject to voluntary facilitation and inhibition.[6]

In healthy individuals, the lower urinary tract has two discrete phases of activity: the storage (or guarding) phase, when urine is stored in the bladder; and the voiding phase, when urine is released through the urethra. The state of the reflex system is dependent on both a conscious signal from the brain and the firing rate of sensory fibers from the bladder and urethra.[6] At low bladder volumes, afferent firing is low, resulting in excitation of the outlet (the sphincter and urethra), and relaxation of the bladder.[7] At high bladder volumes, afferent firing increases, causing a conscious sensation of urinary urge. When the individual is ready to urinate, he or she consciously initiates voiding, causing the bladder to contract and the outlet to relax. Voiding continues until the bladder empties completely, at which point the bladder relaxes and the outlet contracts to re-initiate storage.[6] The muscles controlling micturition are controlled by the autonomic and somatic nervous systems. During the storage phase the internal urethral sphincter remains tense and the detrusor muscle relaxed by sympathetic stimulation. During micturition, parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. The external urethral sphincter (sphincter urethrae) is under somatic control and is consciously relaxed during micturition.

It is commonly believed that in infants, voiding occurs involuntarily (as a reflex). However, the practice of elimination communication suggests otherwise.[citation needed] The ability to voluntarily inhibit micturition develops by the age of 2–3 years, as control at higher levels of the central nervous system develops. In the adult, the volume of urine in the bladder that normally initiates a reflex contraction is about 300–400 millilitres (11–14 imp fl oz; 10–14 US fl oz)

During storage, bladder pressure stays low, because of the bladder's highly compliant nature. A plot of bladder (intravesical) pressure against the depressant of fluid in the bladder (called a cystometrogram), will show a very slight rise as the bladder is filled. This phenomenon is a manifestation of the law of Laplace, which states that the pressure in a spherical viscus is equal to twice the wall tension divided by the radius. In the case of the bladder, the tension increases as the organ fills, but so does the radius. Therefore, the pressure increase is slight until the organ is relatively full. The bladder's smooth muscle has some inherent contractile activity; however, when its nerve supply is intact, stretch receptors in the bladder wall initiate a reflex contraction that has a lower threshold than the inherent contractile response of the muscle.

Action potentials carried by sensory neurons from stretch receptors in the urinary bladder wall travel to the sacral segments of the spinal cord through the pelvic nerves.[6] Since bladder wall stretch is low during the storage phase, these afferent neurons fire at low frequencies. Low-frequency afferent signals cause relaxation of the bladder by inhibiting sacral parasympathetic preganglionic neurons and exciting lumbar sympathetic preganglionic neurons. Conversely, afferent input causes contraction of the sphincter through excitation of Onuf's nucleus, and contraction of the bladder neck and urethra through excitation of the sympathetic preganglionic neurons.

Diuresis (production of urine by the kidney) occurs constantly, and as the bladder becomes full, afferent firing increases, yet the micturition reflex can be voluntarily inhibited until it is appropriate to begin voiding.

Voiding begins when a voluntary signal is sent from the brain to begin urination, and continues until the bladder is empty.

Bladder afferent signals ascend the spinal cord to the periaqueductal gray, where they project both to the pontine micturition center and to the cerebrum.[8] At a certain level of afferent activity, the conscious urge to void becomes difficult to ignore. Once the voluntary signal to begin voiding has been issued, neurons in pontine micturition center fire maximally, causing excitation of sacral preganglionic neurons. The firing of these neurons causes the wall of the bladder to contract; as a result, a sudden, sharp rise in intravesical pressure occurs. The pontine micturition center also causes inhibition of Onuf's nucleus, resulting in relaxation of the external urinary sphincter.[9] When the external urinary sphincter is relaxed urine is released from the urinary bladder when the pressure there is great enough to force urine to flow out of the urethra. The micturition reflex normally produces a series of contractions of the urinary bladder.

The flow of urine through the urethra has an overall excitatory role in micturition, which helps sustain voiding until the bladder is empty.[10]

For land mammals over 1 kilogram, the duration of urination does not vary with body mass, being dispersed around an average of 21 seconds (standard deviation 13 seconds), despite a 4 order of magnitude (1000×) difference in bladder volume.[11][12] This is due to increased urethra length of large animals, which amplifies gravitational force (hence flow rate), and increased urethra width, which increases flow rate. For smaller mammals a different phenomenon occurs, where urine is discharged as droplets, and urination in smaller mammals, such as mice and rats, can occur in less than a second.[12] The posited benefits of faster voiding are decreased risk of predation (while voiding) and decreased risk of urinary tract infection.

The mechanism by which voluntary urination is initiated remains unsettled.[13] One possibility is that the voluntary relaxation of the muscles of the pelvic floor causes a sufficient downward tug on the detrusor muscle to initiate its contraction.[14] Another possibility is the excitation or disinhibition of neurons in the pontine micturition center, which causes concurrent contraction of the bladder and relaxation of the sphincter.[6]

There is an inhibitory area for micturition in the midbrain. After transection of the brain stem just above the pons, the threshold is lowered and less bladder filling is required to trigger it, whereas after transection at the top of the midbrain, the threshold for the reflex is essentially normal. There is another facilitatory area in the posterior hypothalamus. In humans with lesions in the superior frontal gyrus, the desire to urinate is reduced and there is also difficulty in stopping micturition once it has commenced. However, stimulation experiments in animals indicate that other cortical areas also affect the process.

The bladder can be made to contract by voluntary facilitation of the spinal voiding reflex when it contains only a few milliliters of urine. Voluntary contraction of the abdominal muscles aids the expulsion of urine by increasing the pressure applied to the urinary bladder wall, but voiding can be initiated without straining even when the bladder is nearly empty.

Voiding can also be consciously interrupted once it has begun, through a contraction of the perineal muscles. The external sphincter can be contracted voluntarily, which will prevent urine from passing down the urethra.

Voiding can be facilitated by immersing a hand in a cup or sink full of warm water.[citation needed] The mechanism is unclear. The phenomenon (and perhaps immersion diuresis) has given rise to the trick of immersing the hand of a sleeping person in water to make this victim urinate in sleep, although the efficacy of the trick is disputed.

The need to urinate is experienced as an uncomfortable, full feeling. It is highly correlated with the fullness of the bladder.[15] In many males the feeling of the need to urinate can be sensed at the base of the penis as well as the bladder, even though the neural activity associated with a full bladder comes from the bladder itself, and can be felt there as well. In females the need to urinate is felt in the lower abdomen region when the bladder is full. When the bladder becomes too full, the sphincter muscles will involuntarily relax, allowing urine to pass from the bladder. Release of urine is experienced as a lessening of the discomfort.

There are three major types of bladder dysfunction due to neural lesions: (1) the type due to interruption of the afferent nerves from the bladder; (2) the type due to interruption of both afferent and efferent nerves; and (3) the type due to interruption of facilitatory and inhibitory pathways descending from the brain. In all three types the bladder contracts, but the contractions are generally not sufficient to empty the viscus completely, and residual urine is left in the bladder. Paruresis, also known as shy bladder syndrome, is an example of a bladder interruption from the brain that often causes total interruption until the person has left a public area. As these people may have difficulty urinating in the presence of others and will consequently avoid using urinals directly adjacent to another person. Alternatively, they may opt for the privacy of a stall or simply avoid public toilets altogether.

When the sacral dorsal roots are cut in experimental animals or interrupted by diseases of the dorsal roots such as tabes dorsalis in humans, all reflex contractions of the bladder are abolished. The bladder becomes distended, thin-walled, and hypotonic, but there are some contractions because of the intrinsic response of the smooth muscle to stretch.

When the afferent and efferent nerves are both destroyed, as they may be by tumors of the cauda equina or filum terminale, the bladder is flaccid and distended for a while. Gradually, however, the muscle of the "decentralized bladder" becomes active, with many contraction waves that expel dribbles of urine out of the urethra. The bladder becomes shrunken and the bladder wall hypertrophied. The reason for the difference between the small, hypertrophic bladder seen in this condition and the distended, hypotonic bladder seen when only the afferent nerves are interrupted is not known. The hyperactive state in the former condition suggests the development of denervation hypersensitization even though the neurons interrupted are preganglionic rather than postganglionic.

During spinal shock, the bladder is flaccid and unresponsive. It becomes overfilled, and urine dribbles through the sphincters (overflow incontinence). After spinal shock has passed, the voiding reflex returns, although there is no voluntary control and no inhibition or facilitation from higher centers when the spinal cord is transected. Some paraplegic patients train themselves to initiate voiding by pinching or stroking their thighs, provoking a mild mass reflex. In some instances, the voiding reflex becomes hyperactive. Bladder capacity is reduced, and the wall becomes hypertrophied. This type of bladder is sometimes called the spastic neurogenic bladder. The reflex hyperactivity is made worse by, and may be caused by, infection in the bladder wall.

Some males prefer to urinate standing while other prefer to urinate sitting or squatting. Elderly males with prostate gland enlargement may benefit from sitting down while in healthy males, no difference is found in the ability to urinate.[16][17] For practising Muslim men, the genital modesty of squatting is also associated with proper cleanliness requirements or awra.[18]

Occasionally, if a male's penis is damaged or removed, or a female's genitals/urinary tract is damaged, other urination techniques must be used. Most often in such cases, doctors will reposition the urethra to a location where urination can still be accomplished, usually in a position that would only promote urination while seated/squatting, though a permanent urinary catheter may be used in rare cases.[citation needed]

It is socially more accepted and more environmentally hygienic for those who are able to urinate in a toilet. Public toilets may have urinals, usually for males, although female urinals exist, designed to be used in various ways.[19]

Sometimes urination is done in a container such as a bottle, urinal, bedpan or chamber pot, also known as a gazunder, e.g. in case of lying sick in bed, in the case that the urine has to be examined (for medical reasons, or for a drug test), or when no toilet is available, and there is no other possibility to dispose of the urine right away.

For the latter application a more expensive solution (hence for special occasions while traveling etc.) is a special disposable bag containing absorbent material that solidifies the urine within ten seconds, making it convenient and safe to keep.[citation needed]

It is possible for both sexes to urinate into bottles in case of emergencies. The technique can help the sickly and the children to urinate discreetly inside cars and in other places without being seen by others.[30]

Acceptability of outdoor urination in a public place other than at a public urinal varies with the situation and with customs. Potential disadvantages include a dislike of the smell of urine, and some exposure of genitals.[citation needed] The latter can be unpleasant for the one who exposes them (modesty, lack of privacy) and/or those who can see them;[citation needed] it can be avoided or mitigated by going to a quiet place and/or facing a tree or wall if urinating standing up, or while squatting, hiding the back behind walls, bushes, or a tree.[citation needed]

The more developed and crowded a place is, the more public urination tends to be objectionable. In the countryside, it is more acceptable than in a street in a town, where it may be a common transgression. Often this is done after the consumption of alcoholic beverages, which causes production of additional urine as well as a reduction of inhibitions. In many places, public urination is punishable by fines, though attitudes vary widely by country. It is often more accepted in Europe[32] and Asia[33] for males, but tends to be socially objectionable for females in most countries.[34][35][36][37][38][39][40]

There was a popular belief in the UK, that it was legal for a man to urinate in public so long as it occurred on the rear wheel of his vehicle and he had his right hand on the vehicle, but this is not true.[41] Public urination still remains more accepted by males in the UK, although British cultural tradition itself seems to find such practices objectionable.[42] For Muslims, it is haram to urinate while facing the Qibla, or to turn one's back to it when urinating or relieving bowels.[43]

Depending on the culture, adult women, unlike men, are restricted in where they can urinate.[44] According to some medical studies, women generally need to urinate more frequently than men due to having smaller bladders. Resisting the urge to urinate because of lack of facilities can promote urinary tract infections which can lead to more serious infections and, in rare situations, can cause renal damage in women.[45][46]Female urination devices are available to help women to urinate discreetly.

Discussions about the optimal position in which to urinate are quite common amongst men, especially in the West. The standing position is often regarded as superior and masculine to the sitting and as a way to differentiate men from women. However, in public conveniences and sometimes at home, men are urged to use the sitting position as to diminish spattering of urine.[17] Arguments in these discussions are often based on these beliefs, and evidence for medical superiority was heterogenic.

A meta-analysis on these studies showed that males with an enlarged prostate urinated better in the sitting position compared to the standing. The amount of residual urine in the bladder was significantly reduced, and there was a trend towards a more powerful flow and shorter voiding time. Combined, this reduces the risk of bladder stones and urinary tract infections. The same study showed that healthy males were not influenced by position, meaning that they could urinate in either position.[16]

A systematic review meta-analysis on the effect of voiding position on the quality of urination found that in elderly males with benign prostate hyperplasia, the sitting position was superior compared with the standing.[47][48] Healthy males were not influenced by voiding position.

A literature review found cultural differences in socially accepted voiding positions around the world found many differences in preferred position: in the Middle-East and Asia, the squatting position was more prevalent, while in the Western world the standing and sitting position was more common.[49]

While it is uncommon for women to stand while urinating, this practice is becoming more common. Denise Decker, a nurse who advocates for this practice, surveyed 600 women to discover how interested they were in having female urination devices that would allow them to urinate in a standing position, and the majority of respondents indicated a desire to have such a device.[50]

A partially squatting position (or "hovering") while urinating, often done to avoid sitting on a potentially contaminated toilet seat, may leave urine behind in the bladder.[51] It can also result in urine landing on the toilet seat.

In many societies and in many social classes, even mentioning the need to urinate is seen as a social transgression, despite it being a universal need. Even today, many adults avoid stating that they need to urinate.[52][53]

Many expressions exist, some euphemistic and some vulgar. For example, centuries ago the standard English word (both noun and verb, for the product and the activity) was "piss", but subsequently "pee", formerly associated with children, has become more common in general public speech. Since elimination of bodily wastes is, of necessity, a subject talked about with toddlers during toilet training, other expressions considered suitable for use by and with children exist, and some continue to be used by adults, e.g. "weeing", "doing/having a wee-wee", "to tinkle", "potty".[citation needed]

Other expressions include "squirting" and "taking a leak", and, predominantly by younger persons for outdoor female urination, "popping a squat", referring to the position many women adopt in such circumstances. National varieties of English show creativity. American English uses "to whiz".[54]Australian English has coined "I am off to take a Chinese singing lesson", derived from the tinkling sound of urination against the China porcelain of a toilet bowl.[55]British English uses "going to see my aunt", "going to see a man about a dog", "to piddle", "to splash (one's) boots", as well as "to have a slash", which originates from the Scottish term for a large splash of liquid.[56] One of the most common, albeit old-fashioned, euphemisms in British English is "to spend a penny", a reference to coin-operated pay toilets, which used (pre-decimalisation) to charge that sum.[57]

Urolagnia is an inclination to obtain sexual enjoyment by looking at or thinking of urine or urination.[58] As a paraphilia, urine may be consumed, or the person may bathe in it. Drinking urine is known as urophagia, though uraphagia refers to the consumption of urine regardless of whether the context is sexual. Involuntary urination during sexual intercourse is common, but rarely acknowledged. In one survey, 24% of women reported involuntary urination during sexual intercourse; in 66% of sufferers urination occurred on penetration, while in 33% urine leakage was restricted to orgasm.[59]

Female kob may exhibit urolagnia during sex, one female will urinate while the other sticks her nose in the stream.[60][61]

A male Patagonian mara, a type of rodent, will stand on his hind legs and urinate on a female’s rump, to which the female will respond by spraying a jet of urine backwards into the face of the male.[62] The male’s urination is meant to repel other males from his partner while the female’s urination is a rejection of any approaching male when she is not receptive.[62] Both anal digging and urination are more frequent during the breeding season and are more commonly done by males.[63]

A male porcupine urinates on a female porcupine prior to mating, spraying the urine at high velocity.[64][65][66][67][68]

"Urine spraying" redirects here. For spraying of urine as an animal repellent, see Animal repellent.

A male elephant urinating

While the primary purpose of urination is the same across the animal kingdom, urination often serves a social purpose beyond the expulsion of waste material. In dogs and other animals, urination can mark territory or express submissiveness.[69] In small rodents such as rats and mice, it marks familiar paths.

The urine of animals of differing physiology or sex sometimes has different characteristics. For example, the urine of birds and reptiles is whitish, consisting of a pastelike suspension of uric acid crystals, and discharged with the feces of the animal via the cloaca, whereas mammals' urine is a yellowish colour, with mostly urea instead of uric acid, and is discharged via the urethra, separately from the feces. Some animals' (example: carnivores') urine possesses a strong odour, especially when it is used to mark territory or communicate in other ways.[clarify]

Ring-tailed lemurs have also been shown to mark using urine. Behaviorally, there is a difference between regular urination, where the tail is slightly raised and a stream of urine is produced, and the urine marking behavior, where the tail is held up in display and only a few drops of urine are used.[73][74] The urine-marking behavior is typically used by females to mark territory, and has been observed primarily at the edges of the troop's territory and in areas where other troops may frequent.[75] The urine marking behavior is also most frequent during the mating season, and may play a role in reproductive communication between groups.[73] Some other primate species use also urine for scent-marking. The white-headed capuchin sometimes engages in a practice known as "urine washing", in which the monkey rubs urine on its feet.[76] Urine washing, in which urine is rubbed on the hands and feet, is also used by the Panamanian night monkey.[77] In some cases, strepsirrhines may also anoint themselves with urine.[78]

Domestic dogs mark their territories by urinating on vertical surfaces (usually at nose level), sometimes marking over the urine of other dogs.[88] When one dog marks over another dog's urine, this is known as "counter-marking" or "overmarking".[89][90] Male dogs urine-mark more frequently than female dogs,[91] typically beginning after the onset of sexual maturity.[92] Male dogs, as well as wolves, sometimes lift a leg and attempt to urinate even when their bladders are empty – this is known as a "raised-leg display",[93][94][95][95][96] "shadow-urination",[97] or "pseudo-urination".[98] They typically mark their territory due to the presence of new stimuli or social triggers in a dog's environment, as well as out of anxiety.[99] Marking behavior is present in both male and female dogs, and is especially pronounced in male dogs that have not been neutered.[99]

Raised-leg urination is the most significant form of scent marking in wolves, and is most frequent around the breeding season.[100] Wolves urine-mark more frequently when they detect the scent of other wolves, or other canid species.[101] Leg-lifting is more common in male wolves than female wolves, although dominant females also use the raised-leg posture.[102] Other types of urine-marking in wolves are FLU (flexed-leg urination), STU (standing urination), and SQU (squatting urination).[103]Breeding pairs of wolves will sometimes urinate on the same spot: this is known as "double-marking".[104][105][106][107][108][109] Double-marking is practiced by both coyotes and wolves.,[110][111][112] and also by foxes.[113]

Coyotes mark their territories by urinating on bushes, trees, or rocks.[114] All male coyotes lift their legs when urinating.[115] However, females sometimes also raise their legs, and males sometimes squat.[116] Urine marking is also associated with pair bonding in coyotes[clarification needed][117] Coyotes sometimes urinate on their food, possibly to claim ownership over it.[118]

Red foxes use their urine to mark their territories.[119][120][121][122][123] A male fox raises one hind leg and his urine is sprayed forward in front of him, whereas a female fox squats down so that the urine is sprayed in the ground between the hind legs.[124][125] Urine is also used to mark empty cache sites, as reminders not to waste time investigating them.[126][127][128] Red foxes use various postures[clarify] to urinate, depending on where they are leaving a scent mark.[124][129]

As in most other canids, male bush dogs lift their hind legs when urinating. However, female bush dogs use a kind of handstand posture, which is less common in other canids.[130][131] When male bush dogs urinate, they create a spray instead of a stream.[132]

Both male and female maned wolves use their urine to communicate, e.g. to mark their hunting paths, or the places where they have buried hunted prey.[133] The urine has a very distinctive smell, which some people liken to hops or cannabis. The responsible substance is very likely a pyrazine, which occurs in both plants.[134] (At the Rotterdam Zoo, this smell once set the police on a hunt for cannabis smokers.[134][135])

Within the Felidae, male felids can urinate backwards by curving the tip of the glans penis backward.[136][137] Urine marking by felids is also known as "spray-urinating"[138] or "spray-marking".[139] To identify their territories, male tigers mark trees by spraying urine[140][141] and anal gland secretions, as well as marking trails with scat. Males show a grimacing face, called the Flehmen response, when identifying a female's reproductive condition by sniffing their urine markings.

A cheetah marking a tree with urine

Lions use urine to mark their territories. They often scrape the ground while urinating, and the urine often flows in short spurts, instead of flowing continuously. They often urinate on vegetation, or on tree trunks at least one meter high.[142] Male lions spray 1–20 jets of urine at an angle of 20–30 degrees upward, at a range of up to 4 meters behind them.[143]

Male cheetahs mark their territory by urinating on objects that stand out, such as trees, logs, or termite mounds. The whole coalition contributes to the scent. Males will attempt to kill any intruders, and fights result in serious injury or death.[144] When male cheetahs urine-mark their territories, they stand a meter away from a tree or rock surface with the tail raised, pointing the penis either horizontally backward or 60° upward.[145] The odor of cheetah urine (unlike that of other large felids) cannot be easily detected by humans.[139]

Black-footed cats use scent marking throughout their ranges, with males spraying urine up to 12 times an hour.[146]